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FOR OFFICE <br /> APPLICATION FOR SANITATIONPam <br /> Permit No. <br /> 10 (Complete in Triplicate) <br /> ---------- l----- ............. ................ <br /> - Date Issued __5`:, <br /> This Permit Expires 1 Year From Date Issued <br /> i <br /> Application is hereby made to the San Joaquin tocat Health District foraermit to construct and install.the work herein <br /> described. This application is made in complia*e With County �rdinance,tlo. 549 and ' isting Rules`and Regulation <br /> JOB ADDRESS/LOCATE ----- _ __-------CENSUS .TRACT _._ _-_......_-,. <br /> Owner's Name = - •--- •--------- ---- ._Ph ne <br /> 46 <br /> ..... <br /> Address -------- ----------11/ City <br /> Contractor's Name ------ ------- --__ __ -_,_-- ..........Li # ..../t....... Phone <br /> Installation will serve: Re 'de ent House Q Commercial oTrailer Court , <br /> Motel Oth -- . ----- -•--- ............ <br /> 01 <br /> Number of livin nit : ---- Number of b s ....... --- age Grinder --- Li Size , ----F-,......... ....... <br /> Water Su Pu #em and name -- - -- ----- Private, <br /> PPI~ <br /> Cho of 3 feet: Sand's Silt 0 Clay ❑ Peat❑ San �] Clay Loa` ,�] <br /> ,: _ _ , <br /> --... � A be' Fitl'Nlaterial If YsPe <br /> JPA <br /> } ptaT, s wm ii of lot, location of system i relation to wells, buildings, a ., niust'be placed reg a side.) <br /> AL TION: (No sep titan r seepage pi permitted i public,sewer is av ilowe within 208 feet) ; : <br /> GE TREATMENT ( } S TIC T [ ] j Si __.�_---_._.. ;- Liquid Depth - e__ • r <br /> ilAater <br /> b Capacity --- - ----- -------- TYI� ---- ---------- �- --------------1- Cctm{aa _ ..._.__.._..,...._. <br /> Distance to nearest: Well _..`__ ________ ___:_.__ __._..Foundation ..___ Prop. !i e_ <br /> ". <br /> LEA HlNG LIN '' } No. of Lines -----:---------- -- -- .ength of each line_--- ------ Y- Total Length. --:.. .......... <br /> t 'D' Box _ _ Type Filter Material Filter Material _ ' <br /> Distance to nearest. Well __.-- ------ ,_. .-aundat-ion- ...... 'Property;,ll . <br /> SEE AGE PIT j Depth -------------------- Diameter=__-- -----___-- Number --------------------- - _- <br /> f - Rock Filled es [} Nojo <br /> Water Table Del4i--- -------------------------------------------Rock Size :., _____:_ <br /> ° Distance to.nearest. Well _________ ________ _ ________....._Foundation ------ _ •- ...... Prop. Li <br /> REPAIR I (E> Z. Sanitation Permit# ____:- Date .....:.. ......... .•_--- ---_) ; <br /> Septic Tac eeify Requirements) -_____ #__. <br /> ---- -- .. <br /> Disposal Fi (Specify.Requirements) <br /> ...... •-••-= •-_- . --- .��--- •- a <br /> .. <br /> (Draw'existing and-required addition on rev [se side) <br /> I hereby certify that I have prepared this application and that the work will be done h accordance moh San Joaquln' <br /> County Ordinances, State laws, and-Rules andRegulations of the: San Joaquin Local h District. Homo owner or Ilcen <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this,permit,is issued, I shall not` ploy,:any Pers in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -- ~0v+rner r 1 <br /> BYri :.-- title <br /> ------ --- - - ------------------------------------------- <br /> ­----------­-- <br /> (I of er wner) <br /> USE, ONLY <br /> APPLICATION ACCEPTED BY -- -- --- -- ----• - ----•- - ----------------------_ . DATE - ..- ...... ............... <br /> BUILDING PERMIT ISSUED ---------------- DATE <br /> ---. <br /> ADDITIONAL COMMENTS-__ __ ._. <br /> ---------- <br /> ---- -- - <br /> --- ------ ------ --- -- <br /> -- --- ----- <br /> Final Inspection bYi✓ = - •----------_--_-----­---- -------------------------- <br /> D ats"7"' AF .� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev.5M <br />